Pharmaceutical Management Medicaid 2017
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1 Pharmaceutical Management Medicaid 2017 Customer Service: (888) TTY: 711 Pharmacy Administration: (810) Visit our website at: McLarenHealthPlan.org MHP /2017
2 Introduction Pharmaceutical management promotes the use of the most clinically appropriate, safe and cost effective medications. McLaren Health Plan s (MHP) Medicaid Drug Formulary is based upon the Michigan Medicaid Common Drug Formulary (Common Formulary). The use of the Common Formulary is a requirement of all Medicaid health plans in the state of Michigan. One or more medications are available in all required drug classes. The drug formulary can be found on our website at McLarenHealthPlan.org or through the Epocrates system. In addition to the drug formulary, MHP has a Quick Formulary Guide (Quick Guide). The Quick Guide is a list of commonly prescribed medications which are covered by MHP. The Quick Guide is sorted by drug class and can be found in new member packets, on the website or by calling our Customer Service Department at (888) Covered Benefits - Medications listed on the Common Formulary. - Federal legend drugs identified on the MHP -Medicaid Drug Formulary. - Select over-the-counter (OTC) items, identified on the MPPL, prescribed by a prescribing provider. - Diabetic supplies limited to needles, syringes, alcohol swabs, lancets and Bayer manufactured test strips. Non-Covered Benefits - Medications that are not listed on the MPPL. - Medications prescribed for cosmetic or convenience purposes. - Experimental or unproven use of medications. McLarenHealthPlan.org Page 2
3 - Medications which are excluded from coverage under Michigan Medicaid, including but not limited to the following: o Diet aids. o Cough and cold medications. o Sexual enhancement or Erectile Dysfunction Medications. o Medications used to promote fertility. - Medical foods or agents that are not regulated by the Food and Drug Administration. In addition, the drug benefit does not reimburse for drug products acquired for or administered in an inpatient hospital, an outpatient hospital emergency room or clinic, a physician s office or clinic. Michigan Department of Health and Human Services (MDHHS) Carve Out Program MDHHS has created a list of medications that are not reimbursable under MHP. These medications are identified on the drug formulary as Carved Out. Any medication listed as Carved Out should be billed to straight (Fee-For-Service) Medicaid. For questions regarding a medication identified as Carved Out, please contact the Magellan Medicaid Beneficiary Help Line at (877) Dispense as Written (DAW) and Generic Mandate Policy Automatic generic substitution is required on all prescriptions. If a generic form of a medication is available and a provider feels the brand name is medically necessary, the prior authorization process can be used (see Prior Authorization/Drug Exception Request section below). McLarenHealthPlan.org Page 3
4 Prior Authorization/Drug Exception Request Certain medications are identified as having a Prior Authorization (PA) restriction. PA means special approval must be given by MHP before the medication will be covered through a pharmacy. A medication may require a PA due to safety concerns or to ensure a more cost effective formulary alternative can be used. If a prescribing provider feels a medication which requires PA is medically necessary than a PA form (see page 6), should be completed by the prescribing provider and faxed to the number indicated on the form. Please contact MHP at (888) if you have questions regarding the PA process or the status of a PA request. Note: If the member is in need of an emergency supply of a medication that requires PA, please contact our Customer Service Department at (888) for assistance. Step Therapy (ST) Edits Step Therapy Edits allow MHP to define a sequence of medication alternatives. MHP provides coverage for medications indicated as Step Therapy required after a list of formulary alternatives have been tried and failed. Compounded Medications All compounded medications require PA. Upon approval the medication must be obtained through an in-network compounding pharmacy and billed to MHP electronically. Paper claims submitted by an out-of-network compounding pharmacy will not be accepted. Specialty Pharmacy (SP) Medications Specialty Pharmacy (SP) medications are used to treat complex medical conditions and may require special storage and handling. Medications on the drug formulary identified with a SP restriction, upon PA approval, must be obtained via a MHP approved specialty pharmacy. The specialty pharmacy will mail the specialty pharmacy medication to the member s home or to the prescribing provider s office. Some examples of specialty pharmacy agents are medications used to treat cancer, endometriosis, Hepatitis C, multiple sclerosis, osteoporosis and rheumatoid arthritis. McLarenHealthPlan.org Page 4
5 Dose Optimization and Quantity Limits Quantity limits (QL) are used to ensure patient safety, increase patient compliance and decrease pharmacy costs. Medications with quantity limits are identified on the drug formulary with a QL restriction. MHP may limit the quantity of a medication to: - A specified quantity per day, month or year. - A specified quantity per lifetime. - A specified quantity across a drug class. Note: If a prescribing provider feels a different quantity is medically necessary for a patient, a request for PA should be submitted to the MHP for review. Drug Formulary Review and Modification A committee of health professionals (doctors and pharmacists) maintains the Common Drug Formulary. This committee meets a minimum of four times per year to review changes in the market which may affect the drug formulary. Changes in the market may include, but are not limited to: - Drug Recalls. - Marketplace withdrawals or product discontinuation. - New generic availability. - New medication releases. Prescribing providers may ask for a modification to the drug formulary by contacting our Pharmacy Administration Department at (810) or by faxing a written request to (810) Requests for formulary modification will be reviewed by our Pharmacy Administration Department and then taken to the formulary committee for determination. McLarenHealthPlan.org Page 5
6 McLarenHealthPlan.org Page 6
7 McLarenHealthPlan.org Page 7
8 McLarenHealthPlan.org Page 8
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